METASTATIC

BONE TUMOUR
By : Muhammad Aiman
Farah Hidda
Mujaahid
Faiz Hakimi
 Introduction
• Bone is the 3rd most common site for metastatic disease (behind lung and liver)
• Most common reason for a destructive bone lesion in adults
• Commonest source (commonest to less common)
• Breast
• Prostate
• Kidney
• Lung
• Thyroid
• Bladder
• GI tract
• No primary tumor is found (10%)
• Commonest site for bone metastasis

Vertebrae > Pelvis > Proximal half of femur > Humerus

• Spread is usually via blood stream

• Occasionally, visceral tumors spread directly to adjacent bones
• Metastases are usually osteolytic
• Pathological fractures are common.
• Bone resorption is due either to direct action of tumor cells or tumor
derived factors that stimulate osteoclastic activity.
• Osteoblastic lesions (uncommon; usually occur in prostatic carcinoma)
Sites and associated condition
Carcinomas that are Commonest site for bone
commonly spread to bone metastasis
•Breast •Vertebrae
•Prostate •Pelvis
•Kidney
•Proximal half of the femur
•Lung
•Humerus
•Thyroid
•Bladder
•GIT Spread via direct invasion/ blood
stream
 Mechanism of metastasis
1. Via tumor cell intravasation
• E cadherin cell adhesion molecule (CAM) release from primary tumor focus
into bloodstream
• PDGF promotes tumor migration
2. Avoidance of immune surveillance
• Once in vessel, tumor cell interact with resident host-blood borne cell
(erythrocyte, T cell, neutrophil, platelet)
• Facilitate survival in the circulation
3. Target tissue localization
• chemokine ligand 12 in the stromal cells bone marrow acts as homing
chemokine to certain tumor cells and promote targeting of bone
4. Extravasation into the target tissue
5. Induction of angiogenesis
• via vascular endothelial growth factor (VEGF) expression
 Mechanism of vascular spread
• Batson vertebral plexus
• Valveless venous plexus of the spine
• Provides a route of metastasis from organs to axial
structure
• Vertebral bodies
• Pelvis
• Skull
• Proximal limb girdles
• Arterial tree metastasis
• Mechanism by which lung and renal cancer spread to
the distal extremities
 Mechanism of bone lysis
• Oncogenic cell releases cytokines IL-6, IL-11,
PTHrP, TGF-beta
• PTHrP and TGF-beta activate osteoblasts
• Osteoblasts secrete RANKL, that binds to
RANK on osteoclasts and activates osteoclasts
Clinical features
Common in age of 50 – 70 years old
1.Pain – the commonest and often the only clinical features
•It depends on the location of the metastasis, any nerve compression by the tumour or nerve injury due to
extension of the bone metastasis.
•character of the pain
•Somatic : aching, sharp or well localised
•Neuropathic: burning, shooting or radiating
•Pain exacerbated by movement of joint or bone involved
•Pain usually worsens at night (tumorigenic pain) due to inflammatory cells secreted by the tumour
2.Pathological fracture
•Common site of long bones: femur, tibia and humerus
•Proximal femur is the most common affected site
•Femoral neck – 50%
•Subtrochanteric – 30%
Intertrochanteric – 20%

Pathological fracture of the vertebrae

•Thoracic/lumbar - Pain during sitting or standing
•Thoracolumbar junction – pain in recumbency
•Cervical spine – pain on flexion and extension of the neck
•Atlanto-axial junction – rotational pain
Pathological fracture of the pelvic
•Pain radiate into the buttock
•Tumour of the pelvis cause compression of the sciatic nerve
3.Symptoms of hypercalcemia
•Anorexia, nausea, thirst, polyuria, abdominal pain, general weakness
4. Neurological deficits
•Compression of the spinal cord in metastatic disease to the spine
•Weakness, numbness, tingling
INVESTIGATION
NURFARAH HIDDA
 Investigation
Blood investigation Imaging
Full blood count Xray
ESR
CT scan
Liver function test
MRI
Calcium level
Radioscintigraphy
Tumor marker
PET scan
Biopsy ( CT-guided biopsy)
Blood investigation
Test Expected result Explanation
Bone marrow function become compromised,
Hb (FBC) Reduced
resulting in anaemia
Chronic inflammation ( tumour progression
ESR Elevated
stimulate inflammation)
Alkaline Indicator of osteoblast metabolism, and it is
Elevated
phosphatase ( ALP) relatively a specific marker for osteogenesis
Osteolytic metastases and excessive calcium release
Calcium Elevated
from bone
Breast CA : CA15-3,CEA, HER2
Tumour marker
Prostate CA : PSA
Imaging (X-ray)
• X-ray allows us to determine whether the tumour is osteolytic, osteoblastic,
mixed, or if there is a change due to tumour-like change similar to Paget’s disease
or brown tumour.
Lytic bone metastasis Blastic bone metastasis
• thyroid cancer • prostate carcinoma (most common)
• renal cell cancer • breast carcinoma (may be mixed)
• adrenal gland carcinoma and • transitional cell carcinoma (TCC)
phaeochromocytoma • Carcinoid
• uterine carcinoma • medulloblastoma
• gastrointestinal carcinomas • neuroblastoma
• Wilms tumor
• Ewing sarcoma
Osteolytic Osteoblastic

• rarified areas in the medulla • mottled increase in density

• moth-eaten appearance in the cortex; • Poor defined margin
sometimes
• marked bone destruction, with or
without a pathological fracture.
mottled appearance of the medial surface of moth appearane vertebral
the diaphysis sclerotic bone appearance from compression
prostate CA fractures
 CT scan
CT scan
•To assess the integrity of the bone cortex
at a site with a known bone metastasis
•Can detect osteolytic and osteoblastic
metastases within the bone marrow
before there is destruction sufficient to
become evident on radiography
•Enables high-resolution visualization of
the bone cortex which can aid in the
diagnosis of a pathologic fracture
MRI
• Allows better delineation of the extent of tumor
• Particularly useful for patients with spine
metastases to evaluate the extent of medullary and
extraspinal disease
• T1 : decreased signal reflecting the replacement of
fat with water-containing tumor
• T2 : metastases usually have a higher signal than
surrounding normal bone marrow
• MRI without contrast should be used
when spinal cord compression and/or
epidural disease/nerve root
impingement is suspected because of
the excellent soft tissue resolution
Radioscintigraphy
• Bone scans with 99mTc-MDP are the most sensitive
method of detecting ‘silent’ metastatic deposits in
bone
• 99m-Tc-methylene diphosphonate (99mTc-MDP) is
the most commonly used tracer.
• It accumulates in areas of increased osteoblastic
activity, provides a total skeletal examination, and is
reliable for detecting metastases in diseases like
prostate and breast cancers
• Bone scan is less sensitive for detecting tumors with
little to no osteoblastic activity (such as multiple
myeloma) and for aggressive lesions with rapid bone
destruction
• This is because it detects osteoblastic activity
resulting in new bone formation.
 Pet Scan
• 18F-fluorodeoxyglucose positron emission tomography/CT
(FDG PET/CT)
• High sensitivity and specificity for diagnosis of distant
metastases, including the bone
Benefit:
 well-established role in cancer diagnosis, staging and
treatment response monitoring
 useful for differential diagnosis of suspected bone lesions
in patients with known cancer
 major benefit of FDG-PET over bone scan is its ability to
screen for distant metastases at sites other than bone
When patients who do not have diagnosed cancer disease
initially present with suspicious bone lesions, PET/CT to screen
the entire body in a highly sensitive manner provides an
opportunity to search for potential primary malignancies
2/20/2020
Diagnostic biopsy
• Only indicated when : patients of unknown primary cancer who present with a
bone metastasis, and initial staging evaluation fails to delineate the primary
malignancy

• If a primary tumor is known, a skeletal lesion with a typical appearance on

imaging studies (either lytic or osteoblastic) may be presumed to be metastatic
Management
 Pain relief

Preservation/restoration of function
Principle of
management Skeletal stabilization
(symptomatic)
Local tumour control

Radiotherapy
Prognosis
Survivorship at 1 year :
• patients with 4 or 5 of Bauer’s
criteria 50 per cent were alive
• patients with 2 or 3 criteria 25 per
cent were alive
• patients with only 1 or none of the
criteria, the majority survived for
less than 6 months and none were
alive at 1 year.
 Palliative care
Control of pain and metastatic activity
-required in most patients
-powerful narcotics reserved for terminally ill
-Radiotherapy used for both pain and to reduce
metastatic growth, often combined with other forms of
tx like IF
Hypercalcemia
• Can cause renal acidosis, nephrocalcinosis,
unconciousness and coma
• Tx with adequate hydration, reduce calcium intake
and administer bisphosphonates
inhibits bone resorption
inhibits osteoclasts activity
Reduces bone pain
Treatment of limb fractures
• Aim : relieves pain immediately, easier nursing and
patient can ambulate
• Shaft fracture  IF + packing with methyl methacrylate
cement (bone cement)
• Femoral neck fracture  prosthetic replacement
• Postoperative irradiation essential to prevent further
extension of the metastatic lesion
Prophylactic fixation
• Large deposits threatening to fracture, tx by IF while
bone still intact
• 50% of a single cortex of a long bone in any
radiological view has been destroyed fracture
should be regarded as inevitable
Spinal metastasis
• 41 to 70 percent of malignant tumors have spinal
metastasis
• Mostly thoracic spine, mainly on vertebral body
• Aim of treatment : reduce pain, maintain urinary and
fecal continence, preserve ability to walk
• Fitting brace
 stable spine following pathological fracture
• Operative stabilization (ant/post spinal fusion)
 spinal instability that causes severe pain, cannot sit or
stand – with or without braces
MRI/CT scan incld. in preoperative assessment to establish
if cord threatened  spinal decompression
• Other forms of surgery
Debulking of tumor or removal of a solitary mets by
vertebrectomy and reconstruction